Tommy John Surgeries Are Down In MLB. Will It Last?

Shohei Ohtani will likely need Tommy John surgery after the season ends.

Loren Elliott / MLB Photos via Getty Images

For many seasons, it seemed like the number of pitchers forced to have Tommy John surgery each year was going to keep climbing forever.

But there’s evidence that something remarkable has happened in the past couple of years: The Tommy John epidemic has slowed.

In 2014, 130 pitchers in major and minor league baseball had the surgery, according to a list maintained by FanGraphs analyst Jon Roegele. There were 143 in 2015, followed by 122 in 2016 and 100 last year. In 2018? So far, 75.

The harder players throw, the more stress is put on the ulnar collateral ligament, a triangular, roughly 1-by-2 centimeter ligament that connects the humerus bone of the upper arm with the ulnar bone of the lower arm. With pitchers throwing faster fastballs nearly every year of the pitch-tracking era, this band of fibers has never been under more stress. Not only are big-name professional players going under the knife, but young amateurs are also entering professional baseball with red flags.

Roegele has recorded 1,483 professional and high-level amateur1 Tommy John surgeries since John’s was performed by Dr. Frank Jobe in 1974. (John pitched in the majors for 14 years after the experimental surgery and notched 164 of his 288 career wins after his elbow was repaired.) It’s been 44 years since that first procedure, and half of the recorded surgeries have occurred in the nearly six and a half years since April 1, 2012. The injury and surgery became such an epidemic in 2014 that a Grantland article described the campaign as “the season Tommy John took.”

The ligament tearing has been estimated to cost teams hundreds of millions of dollars as players typically require a surgery and recovery process that lasts more than a year.

Two of baseball’s most prized arms are staring down that lengthy recovery. Pitching and hitting sensation Shohei Ohtani of the Los Angeles Angels was perhaps the biggest story in baseball this year when, after a three-month hiatus from pitching, his velocity had declined during his start when he took the mound in September. After an MRI, doctors recommended Tommy John surgery. Ohtani will likely not throw another pitch until 2020, and it’s unclear how much he’ll be able to hit next season. Three days after Ohtani’s truncated September start, another one of baseball’s top pitching prospects, Chicago White Sox rookie Michael Kopech, also made what will likely be his last appearance until 2020. In the top of the fourth, Kopech was pulled from the game and Tommy John was recommended not long after.

Baseball fans are all too used to this news, so it would be easy not to notice the slowdown in the surgery rate.

Roegele told FiveThirtyEight that he believes his major league data is nearly complete but that he might have captured only 50 percent of minor league Tommy John surgeries. If we narrow our view to only major league pitchers, surgeries are also down from record levels: The annual number of surgeries is down from its peak of 35 in 2012. In 2016 and 2017, for example, there were 19 and 18 surgeries among major league pitchers, respectively. And so far in 2018, there have been only 17.

But 2018 isn’t over yet. To get a truly apples-to-apples comparisons, we looked at the number of surgeries that had taken place through the same point of every year — in this case, Sept. 12. As you can see from the chart below, the number of surgeries so far is tracking below recent years as well, both among only major league players and among all professional pitchers.

Despite Ohtani and Kopech’s diagnoses, has professional baseball really found a way to slow the surge?

There are several reasons why the trend may be reversing.

For starters, pitchers are throwing fewer pitches: Pitch counts have grown commonplace, and bullpens are absorbing more innings by design.2 There were 20,517 pitching appearances last season — about 1,200 more than there were in 2014. From 2014 to 2018, average pitch counts fell from 96 to 89 per start. The number of pitchers to throw at least 200 innings dropped from 28 in 2015 to 15 in each of the last two seasons.

Dr. Glenn Fleisig studies the stress on pitchers’ elbows and shoulders at the American Sports Medicine Institute, a center in Birmingham, Alabama, that was founded by Tommy John surgeon specialist Dr. James Andrews. The institute and Fleisig believe year-round throwing and focus on velocity training are factors that can lead to the surgery. ASMI and Fleisig also understand the incentives at play for young pitchers. It’s nearly impossible to be drafted in the first round with a sub-90 mph fastball.

Fleisig said medical personnel’s ability to diagnose and address injury has improved but so, too, has the quality of the strength training and conditioning. That might explain some of the decline in the number of annual surgeries, although he cautioned that the recent slowdown has taken place over a small sample of several years.

Fleisig also said teams are more cautious when it comes to workload. “It’s not really science — it’s really art,” he said. “The teams are getting better at the art of [knowing] when to back off.” He noted that at the major league level, pitchers sometimes skip starts, which, he said, “gives the body more time to recover.” And last season, MLB replaced the 15-day disabled list with the 10-day disabled list, which allows teams to better manipulate rosters to rest pitchers.

Science also might be playing a role in the Tommy John dip. New kinds of wearable technology allow teams to monitor workload and fatigue. One example of that is a sleeve, designed by a company called Motus, that measures, among other things, the forces acting on elbows.

Will Carroll, an expert on pitching injuries who now works for Motus, said that one thing the company is discovering is that workload management might be more important than the actual stress on the arm. “Knowing that you have a certain measure of force on your elbow is good information, but for a consistent, pro- or high-level pitcher, they repeat [delivery and force] so much it doesn’t really change. … It’s the workloads that just break people down.”

Carroll said one thing they’ve learned from the technology is that it’s important for pitchers to build up arm strength and stamina properly and that increasing workloads too quickly can be damaging. He also said that counter to the prevailing thought that every pitcher should take some extended time off from throwing during the offseason, some level of year-round throwing might actually be beneficial. He pointed to Cleveland Indians pitcher Trevor Bauer, who is well known for his volume of offseason throwing, as an example of someone who might be taking the right approach. (Bauer has never been placed on the disabled list because of an arm injury.)

That doesn’t mean max-effort throws all year — but some level of throwing activity could help.

Carroll also said more athletes have gone to outside organizations for private instruction, facilities like Driveline Baseball in suburban Seattle, to better understand how to improve performance and health. More individualized routines could be having a positive effect.

Another trend that could be a factor is that pitchers are throwing fewer fastballs.

According to data from pitch-tracking company Pitch Info that’s published at FanGraphs, pitchers are throwing fastballs less often — nearly 61 percent of pitches thrown in 2008 were fastballs, but that number has gradually declined to about 55 percent so far this season. Why does that matter? It’s possible the fastball places more stress on the elbow than breaking and off-speed pitches, which runs contrary to conventional wisdom. A 2014 Henry Ford Hospital study found that pitchers who have had Tommy John surgery threw 7 percent more fastballs than pitchers who had not had the surgery.

There are some experts who don’t believe that baseball is truly experiencing a sustainable drop in Tommy John surgeries. One of those people is Todd Tomczyk, director of sports medicine for the Pittsburgh Pirates. Tomczyk said that while there definitely has been “a tickdown” in the number of procedures in the major leagues, he believes the surgeries have increased in the minor leagues. And he said he and other major league medical staffs are beginning an effort to compile data on all minor league Tommy John surgeries.

Tomczyk is concerned with what he believes is an increasing number of players entering professional baseball with elbow injuries or having already had Tommy John surgery. “What jumps out to me is the draft,” Tomczyk said. “I think we are seeing [effects] of the year-round player, and more and more [youth players] are getting the surgery.”

In the major leagues, meanwhile, the numbers seem to be dropping. Whether the trend is here to stay or it’s just a short-term reprieve isn’t clear. Of course, that won’t give any solace to fans of the Angels and White Sox who are without their most prized pitching prospect for the foreseeable future, but leaguewide, baseball fans can enjoy not hearing the most dreaded two words in the game: Tommy John.

Footnotes

College and high school pitchers who are candidates to play professional baseball.

FiveThirtyEight discussed in 2016 how pitch counts could be affecting the rate of Tommy John surgeries.